From A Formal Training Program In Musculoskeletal Ultrasound (MSUS) To A High Reproducibility for MSUS Ultrasound In Rheumatoid Arthritis.

OBJECTIVE: To assess the intra- and inter-observer reliability of Ultrasound (US) in scoring B-mode, Doppler synovitis and combined B-mode and Doppler synovitis scores in different peripheral joints of Rheumatoid Arthritis (RA) patients. METHODS: Four rheumatologists with a formal training in Musculoskeletal US (MSKUS) particularly focus on definitions and scoring synovitis on B-mode and Doppler mode participated in a patient- based reliability exercise on 16 active RA patients. The four rheumatologists independently and consecutively performed a B-mode and Power Doppler (PD) US assessment of 7 joints of each patient in two rounds in a blinded fashion. Each joint was semi quantitatively scored from 0 to 3 for B-mode Synovitis (BS), Doppler Synovitis (DS), and combined B-mode/Doppler synovitis (CS). Intraobserver reliability was assessed by Cohen's κ. Interobserver reliability was assessed by unweight Light's κ. RESULTS: The mean prevalence of synovitis on B-mode was 83% of joints; scores ranging from grade 1 in 18% of joints, to grade 3 in 33%. In 55% of joints synovial PD signal was detected and the distribution of scores range from 14% of joints for grade 3, to 26% for grade 2. After a total of 448 joints scanned with 896 adquired images our intraobserver and interobserver reliability was good to excellent for most of the joints. CONCLUSION: Formal, structured and continuous training in musculoskeletal ultrasound would bring a good to excellent reproducibility in rheumatological hands with a high reliability in real time acquisition BS, DS and CS modalities for scoring synovitis in patients with active rheumatoid arthritis.

The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology.

BACKGROUND: In 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines. OBJECTIVES: To update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology. METHODS: The project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures). RESULTS: Structures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts. CONCLUSIONS: This task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

Integration of Phytochrome and Cryptochrome Signals Determines Plant Growth during Competition for Light.

Plants in dense vegetation perceive their neighbors primarily through changes in light quality. Initially, the ratio between red (R) and far-red (FR) light decreases due to reflection of FR by plant tissue well before shading occurs. Perception of low R:FR by the phytochrome photoreceptors induces the shade avoidance response [1], of which accelerated elongation growth of leaf-bearing organs is an important feature. Low R:FR-induced phytochrome inactivation leads to the accumulation and activation of the transcription factors PHYTOCHROME-INTERACTING FACTORs (PIFs) 4, 5, and 7 and subsequent expression of their growth-mediating targets [2, 3]. When true shading occurs, transmitted light is especially depleted in red and blue (B) wavelengths, due to absorption by chlorophyll [4]. Although the reduction of blue wavelengths alone does not occur in nature, long-term exposure to low B light induces a shade avoidance-like response that is dependent on the cryptochrome photoreceptors and the transcription factors PIF4 and PIF5 [5-7]. We show in Arabidopsis thaliana that low B in combination with low R:FR enhances petiole elongation similar to vegetation shade, providing functional context for a low B response in plant competition. Low B potentiates the low R:FR response through PIF4, PIF5, and PIF7, and it involves increased PIF5 abundance and transcriptional changes. Low B attenuates a low R:FR-induced negative feedback loop through reduced gene expression of negative regulators and reduced HFR1 levels. The enhanced response to combined phytochrome and cryptochrome inactivation shows how multiple light cues can be integrated to fine-tune the plant's response to a changing environment.

Correlación entre la actividad clínica por DAS-28 y ecografía en pacientes con artritis reumatoide / Correlation between clinical activity measured by DAS-28 and ultrasound in patients with rheumatoid arthritis

INTRODUCCIÓN: La artritis reumatoide es una enfermedad multifactorial, sistémica, crónica, autoinmune e inflamatoria, que afecta fundamentalmente las articulaciones. La ultrasonografía/ecografía ha demostrado utilidad en la detección de sinovitis subclínica; sin embargo, la mayoría de la evidencia disponible es en pacientes en remisión y la evidencia para la correlación con el índice de actividad clínica (DAS-28), en Colombia, es limitada. OBJETIVOS: Establecer la correlación entre la actividad clínica medida por DAS-28 y la ecografía, en pacientes con artritis reumatoide. MATERIALES Y MÉTODOS: Cuarenta pacientes con diagnóstico de artritis reumatoide que iniciaron terapia biológica o leflunomida, fueron incluidos en el estudio descriptivo, longitudinal, prospectivo para evaluar la correlación entre el DAS-28 y la ecografía, en la consulta basal y a los 4 meses.RESULTADOS: Se encontró; correlación entre el índice de actividad clínico de la enfermedad (DAS-28) y el índice de actividad ecográfico (DAS ecográfico), tanto por escala de grises (r=0,943,p<0,01) como por Power Doppler(r =0,946, p <0,01); también se encontró; correlación entre el DAS ecográfico por escala de grises y el DAS ecográfico por Power Doppler (r= 0,953 ,p <0,01). CONCLUSIONES: La ecografía es de utilidad en la detección de inflamación subclínica y los resultados son concluyentes cuando se compara el número de articulaciones inflamadas en la evaluación clínica, con el conteo obtenido en la evaluación ecográfica. La evaluación ecográfica sugiere que las manos son las articulaciones con mejor rendimiento para la medición del grado de sinovitis en la artritis reumatoide

NTRODUCTION: Rheumatoid arthritis is a multifactorial, systemic, chronic, autoimmune, and inflammatory disease that mainly affects the joints. Ultrasound has shown to be useful in detecting subclinical synovitis; however, most of the available evidence is in patients on remission, and the evidence on a correlation with the clinical activity measured by DAS-28, in our midst, is limited. OBJECTIVE: To establish the correlation between clinical activity measured by DAS-28 and ultrasound in patients with rheumatoid arthritis. MATERIALS AND METHODS: A total of 40 patients diagnosed with rheumatoid arthritis who were started on biological therapy or leflunomide were included in the descriptive, longitudinal, prospective study to evaluate the correlation between DAS-28 and ultrasound at baseline visit and 4 months later. RESULTS: A correlation was found between DAS-28 and ultrasound, both by using the grayscale (r = 0.943, p <.01) and the power Doppler (r = 0.946, p <.01). There was also a correlation between the ultrasound DAS by grayscale and ultrasound DAS by power Doppler (r = 0.953, p<.01). CONCLUSIONS: Ultrasound is a useful tool for detecting sub-clinical inflammation and the results are conclusive when comparing the number of swollen joints in the clinical evaluation with the count obtained in the ultrasound assessment. Ultrasound evaluation suggests that the hands are the joints with better performance for measuring the grade of synovitis in rheumatoid arthritis

Antimetabolitos y oro / Antimetabolics and gold

Existen muchas enfermedades reumatológicas asociadas con alteraciones en el sistema inmune, para las cuales es útil el tratamiento con medicamentos como los antimetabolitos azatioprina y metrotexate, y antirreumáticos de acción lenta como las sales de oro. Con estas drogas se han obtenido excelentes resultados en el manejo de enfermedades como la artritis reumatoidea, artritis reumatoidea juvenil, lupus eritematoso sistémico, enfermedad inflamatoria intestinal y miastenia gravis, entre otras

Nefropatia lupica: estudio de 156 casos / Lupic nephropathy: study of 156 cases

Por medio de un estudio de casos y controles se analizaron las historias de 297 pacientes con lupus eritematoso sistemico, atendidos en la consulta externa del Servicio de Reumatologia del Hospital Universitario San Vicente de Paul, en Medellin, Colombia, entre 1970 y 1987. Se documento compromiso renal en 156 (52.5%). Hubo 94 que presntaron alteraciones en el sedimento urinario sin evidencia clinica de lesion renal. La nefropatia como primera manifestacion de la enfermedad se encontro en 14 pacientes (4.7% del grupo total); en 48 de los pacientes que tenian nefropatia (30.8%) se hallo la preoteinuria en rangos nefroticos; en 19 (6.4%) hubo insuficencia renal aguda y en 15 (5.0%) insuficiencia renal cronica. Desde el punto de vista histologico se estudiaron 79 biopsias renales; de ellas 7 (8.9%) fueron clasificadas como glomerulonefritis (GN) mesangial; 17 (21.5%) como GN proliferativa local; 38 (48.1%) como GN proliferativa difusa y 9 (11.4%) como GN membranosa. La fercuencia de las siguientes manifestaciones fue significativamente mayor en pacientes con nefropatia: livedo reticularis, vasculitis, ulceras orales, tromboflebitis, psicosis, cefalea y depresion

By means of a case-control study we analyzed the cllnlcal histories of 297 patients with systemic erythematous lupus, that were seen at the out-patient section of the Rheumatology Service, Hospital Universitario San Vicente de Paúl, in Medellín, Colombia, between 1970 and 1987. Renal involvement was documented in 156 (52.5%) cases while in 94 (31.6%) there were alterations in the urinary sediment without clinical evidence of renal lesions. Nephropathy was the first evidence of disease in 14 patients (4.70¡0 of the total group); in 48 of those with nephropathy proteinuria was in the nephrotic range; acute renal insufficiency was found in 19 patients (6.4%) while in 15 (5.0%) there was chronic renal insufficiency. Seventy nine renal biopsies were performed; their histological classification was as follows: mesangial glomerulonephritis 7 (8.9%); focal proliferative glomerulonephritis 17 (21.5%); diffuse proliferative glomerulonephritis 38 (48.1%) and membranous glomerulonephrltls 9 (11.1 %). The frequency of the following clinical manifestations was significantly higher in patients with nephropathy: Iivido reticularis, vasculitis, oral ulcers, arthritis, thrombophlebitis, psychosis, headache and depression